1999 IOM report: Never events were among the many safety initiatives that that came out of the 1999 IOM report. There are currently 28 Never Events. These events are usually preventable, concern to both public and healthcare professionals, clear cut, clearly identifiable, measurable, and can be included in a report. The risk is related to policies and procedures, serious, resulting in death, loss of body part, and disability. It is adverse, and indicative of a problem with health facilities, and important for integrity and public accountability. These events are aptly named “never events”, as they should never happen. If protocols and procedures are put in place to prevent these errors, and healthcare staff and providers are following these policies and procedures then these events should never happen.

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Centers for Medicare and Medicaid (CMS) announced that federal payor programs will no longer reimburse for treatment of complications related to care. These events are “reasonably preventable if following evidence based guidelines” (O’Rourke, P. T., 2009). Inadequate nurse staffing has been associated with higher rates of adverse events. “The effectiveness of nurse surveillance is influenced by the number of RN’s available to assess patients on an ongoing basis (Di Leonardi, B.C., Faller, M., & Siroky, K. n.d.). CMS offers nurses the opportunity to take on a leadership role in preventing never events (A., 2010). The ability of nurses to prevent medical errors in more than half of all never events are nursing sensitive, especially falls and ulcers. Nurses are now viewed as an investment and this is because when nursing staff is increases, patient care improves (A., 2010).